Centennial High School Orchestra

Medical Consent Form

MEDICAL PERMISSION

My child,__________________________________________, has permission to accompany the Centennial High School Orchestra on the Spring Trip/Performance departing March 29, 2007 and returning on April 1, 2007.  In the event of illness or accident, I hereby give my consent for the necessary emergency medical treatment of said child.  This includes permission for the treatment of my child by a physician at a hospital for any medical or surgical emergency.

Hospital Insurance Company:_____________________________________________________

Policy #____________________________________  Group #___________________________

_____________________________________________________________________________

Parent/Guardian Signature

MEDICAL INFORMATION

My child has permission to take:

Aspirin ____________            Dramamine___________            Alka Seltzer______________

Advil______________            Vitamins_____________            Pepto Bismol_____________

Tylenol____________ Maalox______________           

List by name any medications (prescription and over the counter) presently being used:

_____________________________________________________________________________

List any medical conditions_______________________________________________________

List any allergies________________________________________________________________

Special dietary needs_____________________________________________________________

Note: You must provide your child with an additional set of contacts, glasses, etc.. as appropriate. If your child may need the above medications, please provide an ample supply in the original container.

Sworn and subscribe before me this ___________________day of ___________________, 2007

______________________________________________________

Notary Public